Steve Nelson went to Vietnam thinking he was going to work with computers--but he ended up in combat about 10 times, he said. Nelson shares his experiences of post-traumatic stress disorder and suicidal thoughts while shedding light on the possible implications of serving your country. (Vietnam footage courtesy of National Archives and does not feature Nelson).

Suicide among veterans is not a simple discussion. With veterans making more than half the calls to the National Suicide Prevention Lifeline since 2007, does the adage of the “ultimate sacrifice” need to be revisited?

More than 134,000 people made calls to the lifeline last year. Of those callers, 61 percent identified themselves as veterans, while 7 percent identified themselves as a friend or family of a veteran.

This means that nearly three-fourths of calls made to the lifeline were related to veterans’ issues.

“What we don’t really know is the relationship between the people who are really going to kill themselves and the population who calls,” said Dr. Dean Krahn, chief of the mental health service line at the VA in Madison, Wis.

The relationship may not be known, but the need is salient.

The Department of Veteran Affairs partnered with the lifeline in 2007 to provide these services for veterans. By dialing “1” after calling 1-800-273-TALK, veterans are routed to a lifeline that caters to their specific needs.

But the lifeline was only established in 2004, a few decades after Steve Nelson and others like him returned home from Vietnam.

For 35 years, Nelson never spoke about his war experiences. Instead, he found solace with drugs and alcohol to dull the memories magnified by his post-traumatic stress disorder.

“I’m so fortunate because I’ve gotten a lot of help and support from my family so I really feel good now,” said Nelson, who lives in Chicago.

But that wasn’t always the case for Nelson.

He remembers searching for his 19-year-old friend, Nick, the father of a newborn baby, the morning after an attack in Vietnam. He found his friend dead, lying on the ground, his body cold and dismembered.

“I found his body in pieces—and he was my friend,” said Nelson, his voice breaking.

Although Nelson is now in good spirits—and five years sober—he previously considered suicide as an option to “disappear.”

While the stories of all veterans are unique, there is a general uniting thread: returning from combat leaves you changed. Some veterans can cope; others cannot. Some have suicide ideation, or suicidal thoughts, and others attempt suicide.

One doctor who works with veterans’ mental health issues at Hines VA Medical Hospital in suburban Chicago said the transition to civilian life is difficult.

“One thing that our service men and women are not always good at,” said Thomas Nutter, assistant chief of mental health, “is reaching out for help when they come back.”

And some veterans end up taking their own lives.

It’s the old maxim: the ultimate sacrifice is losing your life while fighting for your country. But with the VA reporting nearly 11,000 non-fatal suicide attempts and about 700 completions in 2009, the definition of the ultimate sacrifice may need to be revisited.

Calls made by veterans to the lifeline have been increasing by about 20,000 each year.

“Part of it is the education and the efforts of the VA,” Krahn said. “Part of it is probably a jump in suicide ideation, but I’m sure it’s not a 100 percent jump.”

But only half of veterans seek out Veterans Health Administration services, provided by the VA, which means that these numbers are likely higher, according to Kristen McDonald, suicide prevention coordinator at the VA Healthcare Center in Palo Alto, Calif.

For the other half not seeking care through the VHA, finding reliable data is difficult.

“What we’re finding is that veterans getting care from [the VA] are less likely to attempt suicide,” McDonald said. There is preliminary evidence suggesting that veterans ages 18 to 29 who use VA health care services, compared to veterans who don’t, have decreased suicide rates, according to McDonald. This decrease translates to about 250 lives per year.

In the same vein of outreach, the VA created an awareness campaign for mass-transit lines in 2008 to help veterans and their families learn about the toll-free crisis lifeline. In late 2010, Chicago became one of the 11 cities in which the campaign was expanded. Advertisements for the lifeline could be found on CTA buses and El platforms around the city.

“One of the lessons we learned when we further expanded our efforts was that the ‘one-size-fits-all’ approach does not work,” said Col. Christopher Philbrick, deputy director of the Army’s Health Promotion Risk Reduction Task Force in Washington, D.C.

“Every suicide is an individual circumstance—the causes behind them and the impacts to make a choice that most don’t consider to be a rational action are fraught with all kinds of twists and turns.”

A holistic approach to mental health, including resiliency training and understanding risk factors are cornerstones of the report. The four pillars of the prevention program are education, reducing stigma, providing resources and involving families.

The report also addresses the misconceptions associated with seeking help as a veteran or soldier.

“It’s the perception that if they notify someone from their organization that they will be stigmatized,” Philbrick said. “A good portion of those have the perception that if they get hold of their military branch they will not receive the support I believe they should.”

The typical non-active duty suicide is committed by a young, white male junior enlisted soldier, according to the report.

“Certainly going to war can be difficult for your mental health,” said Krahn, at the VA in Madison. “Seventeen percent come back with post traumatic stress disorder and others come back with [similar rates of] depression, and a chunk of both of those drink heavily. All three of those increase your suicide risk.”

Gunshot wounds are the most frequent cause of death in these suicides, according to the report.

“For veterans, your weapon is your security. It keeps you safe,” said Nutter, at Hines VA. “As a group, they are more likely to have weapons, and those with weapons in their homes are most likely to complete suicide.”

Nutter reads the chart of each patient who has committed suicide before he writes up an issue brief that is sent to the central VA office in Washington, D.C.

“It’s tricky to know if we have an accurate count of suicides because not everybody walks in and says their family member committed suicide,” Nutter said.

“I think in general the support our vets get when they return home is much, much improved over previous conflicts.”

The services available to veterans now are of higher quality and in more abundance than they were post-Vietnam, Nelson said. There was no such thing as PTSD until much after Vietnam, he said.

Nearly 700 soldiers committed suicide while in Vietnam, according to a spokesman for the 50th Anniversary of the Vietnam War Commemoration Commission.

While no data is publicly available, estimates of suicides committed by Vietnam veterans, depending on the source, range from 2,000 to 300,000.

“The hardest part for everybody to deal with is that lots of people care a lot about this group of people who have risked their lives for us,” Krahn said. “So we all are sort of desperate for a single, simple answer and it’s very unlikely that it’s a single, simple answer. And so I think one of the great risks is that instead of sticking with this project probably for months, years and decades, we’ll get into fights with each other about ‘we invested in this why isn’t it fixed?’”

As for Nelson, the Vietnam veteran, he now donates his time, peer counseling in Chicago neighborhoods as well as counseling other veterans in their time of need.

“I’m able to have the strength to help other people,” he said, “and I love doing that.”